Method of improved vein closure

ABSTRACT

There are disclosed methods of vein closure. In an embodiment, a method includes elevating a leg of a patient during a vein closure procedure so as to effect substantial emptying of the vein. The method also includes applying radio-frequency energy to a vein within the leg of the patient to cause the vein closure. In another embodiment, a method includes elevating a leg of a patient during a vein closure procedure within a range of about 30 degrees to about 45 degrees from a horizontal position. The method also includes applying radio-frequency energy to a vein within the leg of the patient. In one embodiment, a method includes elevating a leg, and emptying of a segment of the vein prior to applying radio-frequency energy. In another embodiment, the method includes elevating a leg of a patient, and applying energy to a vein. Other embodiments are also disclosed.

REFERENCE TO PENDING PRIOR PATENT APPLICATION

This application claims the benefit under 35 U.S.C. 119 (e) of U.S.Provisional Patent Application No. 61/023,404, filed Jan. 24, 2008 byRobert F. Merchant for “Method of Improved Vein Closure,” which patentapplication is hereby incorporated herein by reference.

BACKGROUND

Investigations into the therapeutic use of radiofrequency (RF) energy inman occurred as early as the late 19^(th) and early 20^(th) centuries.Technological advances increased interest in RF applications. Because,of its precise control of energy delivery and reliability, RF energy hasbeen used for decades in neurosurgical techniques. (Liu J K, Apfelbaum RI. Treatment of trigeminal neuralgia. Neurosurg Clint N Amer. 2004;15:319-34.). By the 1980s cardiac arrhythmias were being treated with RFdevices. (Filingeri V, Gravante G, Cassisa D. Physics of radiofrequencyin proctology. Eur Rev Med Pharmacol Sci. 2005;9:349-54.) Usage expandedto include treatment of various malignancies, including hepatic, renal,musculoskeletal, breast, lymph, spleen, pulmonary (Brown D B. Concepts,considerations, and concerns on the cutting edge of radiofrequencyablation. J Vasc Interv Radiol. 2005;16:597-613, and Gillams A R. Theuse of, radiofrequency in cancer. Br J Cancer. 2005;92:1825-9), as wellas ophthalmologic maladies, gastric reflux, sleep apnea and aestheticdermatological conditions. (Berjano E J. Theoretical modeling forradiofrequency ablation: state-of-the-art and challenges for the future.Biomed Eng Online. Apr. 18, 2006;5:24, and Sadick N, Sorhaindo L. Theradiofrequency frontier: a review of radiofrequency and combinedradiofrequency pulsed-light technology in aesthetic medicine. FacialPlast Surg. 2005;21:131-8.) Berjano reported that the number ofscientific papers published on the topic of therapeutic RF energy useincreased from 19 in 1990 to 825 in 2005. (Berjano E J. Theoreticalmodeling for radiofrequency ablation: state-of-the-art and challengesfor the future. Biomed Eng Online. Apr. 18, 2006;5:24.) As a lessinvasive alternative to vein stripping for elimination of saphenous veinreflux, the percutaneous catheter-based radiofrequency Closure®procedure (VNUS Medical Technologies, San Jose, Calif.) was introducedin Europe in 1998, and in the U.S. in 1999.

Following initial experience with the Closure procedure and earlytechnique modifications, it became clear that reflux at thesaphenofemoral junction (SFJ) could be eliminated by obliteration of thegreat saphenous vein in the thigh without resorting to dissection andligation of all contributing branches near the saphenofemoral junction,(Chandler J G, Pichot O, Sessa C, et al. Defining the role of extendedsaphenofemoral junction ligation: A prospective comparative study. JVasc Surg. 2000;32:941-53, and Chandler J G, Pichot O, Sessa C, et al.Treatment of primary venous insufficiency by endovenous saphenous veinobliteration. Vasc Surg. 2000;34:201-14) thus eliminating the need for agroin incision and potential for minor and even major complications thatcan occur following traditional ligation and stripping procedures, andleaving intact venous return and lymphatic drainage from the abdominalwall and lower extremity. The validity of this strategy has been borneout by several published mid-term reports. (Nicolini P; Closure Group.Treatment of primary varicose veins by endovenous obliteration with theVNUS closure system: results of a prospective multicentre study. Eur JVasc Endovasc Surg. 2005;29:433-9; Merchant R F, Pichot O, Myers K A.Four-year follow-up on endovascular radiofrequency obliteration of greatsaphenous reflux. Dermatol Surg. 2005;31:129-34; Pichot O, Kabnick L S,Creton D, et al. Duplex ultrasound scan findings two years after greatsaphenous vein radiofrequency endovenous obliteration. J Vasc Surg.2004;39:189-95; and Lurie F, Creton D, Eklof B, et al. Prospectiverandomised study of endovenous radiofrequency obliteration (closure)versus ligation and vein stripping (EVOLVeS): two-year follow-up. Eur JVasc Endovasc Surg. 2005;29:67-73.) Pichot (Pichot O, Kabnick L S,Creton D, et al. Duplex ultrasound scan findings two years after greatsaphenous vein radiofrequency endovenous obliteration. J Vasc Surg.2004;39:189-95) coordinated an extensive two year follow-up ultrasoundevaluation study from five VNUS, Registry centers. The results showedthat 58/63 (92.1%) treated GSV segments remained free of reflux.Junctional tributary reflux was seen in 7/63 (11.1%) limbs, four ofwhich were associated with the SFJ as the sole source of reflux.Neovascularization was not observed in any treated limbs. More recently,Closure equipment innovations and technique modifications havecontributed to reduced procedure times while maintaining efficacy andlow rates of complications.

For some closure procedures, such as the VNUS Closure procedure, acatheter with a radio-frequency (RF) heating coil may be used to close avein within a leg of a patient. During the procedure, the heating coilmust be drawn down the leg and compression must be maintained over thelength of the heating coil as the patient is supported supine on atable.

Generally, it is very cumbersome to maintain this pressure and anadditional technician may be necessary to maintain such pressure. Theheat from the coil must also be applied for a given amount of time. Thistiming is generally 20 seconds for each 7 cm section of coil, with thefirst segment heated twice, and then periodically repositioned withpressure being regulated. This treatment may take 20 minutes tocomplete. Results from this procedure may be less than optimal due tothe cumbersome and complex pressure maintenance and timing involved.

SUMMARY OF THE INVENTION

In an embodiment, there is provided a method of vein closure, the methodcomprising elevating a leg of a patient during a vein closure procedureso as to effect substantial emptying of the vein; and applyingradio-frequency (RF) energy to a vein within the leg of the patient tocause the vein closure, wherein the radio-frequency (RF) energy isapplied with a heating coil of a catheter within the vein during theprocedure.

In another embodiment, there is provided a method of vein closure, themethod comprising elevating a leg of a patient during a vein closureprocedure within a range of about 30 degrees to about 45 degrees from ahorizontal position; and applying radio-frequency (RF) energy to a veinwithin the leg of the patient to cause the vein closure with the leg ofthe patient elevated within the range of about 30 degrees to about 45degrees.

In yet another embodiment, there is provided a method of vein closure,the method comprising elevating a leg of a patient during a vein closureprocedure; emptying of a segment the vein prior to applyingradio-frequency (RF) energy to the segment of the vein; and applying theradio-frequency (RF) energy to the vein within the leg of the patient tocause the vein closure.

In yet another embodiment, there is provided a method of vein closure,the method comprising elevating a leg of a patient during a vein closureprocedure so as to effect substantial emptying of the vein; and applyingenergy to a vein within the leg of the patient to cause the veinclosure, wherein the energy is applied to the vein during the procedure.

Other embodiments are also disclosed.

BRIEF DESCRIPTION OF THE DRAWINGS

Illustrative embodiments of the invention are illustrated in thedrawings, in which:

FIG. 1 illustrates a distal section of a ClosureFAST catheter, whichcontains a 7 cm long heating element, is depicted heating the greatsaphenous vein (GSV) in a segment starting approximately 2 cm below thesaphenofemoral junction (SFJ).

FIG. 2 illustrates a catheter prior to heating a segment of the vein ata heating element, with a closed segment of the vein to the left of thesegment to be heated by heating element.

FIG. 3 illustrates seven segments of the vein where the heating coil ismaintained during each energy delivery period.

FIG. 4 illustrates the tilt table in this treatment room to allow thetorso of the patient to be in a relatively supine position (wherepatient's head can be seen to the right), while the leg to be treated ispositioned with 30° or more of angulation.

DETAILED DESCRIPTION

In an embodiment, there is disclosed a method of positioning a patientfor a VNUS Closure procedure to close a diseased vein usingradio-frequency (RF) energy to heat the vein wall. In other embodiments,a vein may be closed using other types of heating, which may include,but are not limited to, endoluminal heating with a laser or anotherlight source, steam, other electromagnetic energy. Vein closure isreferred to herein with respect to radio-frequency (RF) energy, but maybe practiced with one or more of these alternatives. The method mayinclude positioning the patient with his or her legs at an angle ofabout 45°. Light pressure may be applied to the catheter heating coilduring initial energy delivery. Sequential indexed heating may becontinued as directed by the usual protocol, but compression is notapplied unless energy and temperature have not reached a target range.

In one embodiment, the method may include elevating a patient's legs soas to empty the vein. Generally, the method includes positioning thepatient's at an angle relative to the torso. In an exemplary embodiment,the angle of the legs relative to the torso is about 45°. In variousembodiments, the leg undergoing the VNUS Closure procedure may beelevated independently during the procedure. The legs may be positionedat various angles that provide elevation so as to cause vein emptying.

For a successful vein closure procedure, the vessel wall must be incontact with the heating tip or coil. Compression of the vein mayprovide mixed results in as much as the catheter may remain eitherpartially or completely bathed in blood. Vein emptying caused byelevation of the legs relative to the torso of the patient allow venousreturn of the blood within the vessel. This emptying of the veinprovides good contact of the heating tip with the vessel wall, which inturn provides improved vein closure.

Other advantages are provided in addition to the improved vein closuredescribed above. For example, the entire vein closure procedure usingthe elevated leg position allows a more smooth movement of the heatingtip of the catheter. The total time of the procedure may be reduced fromabout 20 minutes to about 1.5 minutes (generally less than 2 minutes) totreat an entire thigh of the patient. Another advantage is that thecatheter of the VNUS Closure procedure does not need to be redesigned.To provide better vein closure, other designs and modifications havebeen contemplated which may have increased the length of time for theprocedure.

In one embodiment, the legs are elevated by using a table with a supportfor elevating the legs. Optionally, the table may be configured toinclude an adjustable back support portion. This back support portionmay be positioned upwardly from a horizontal position to an angle ofabout 45°. The table may also include a tilt component. With this tiltcomponent, the portion supporting the patient's back may be adjustedtogether with a leg supporting portion so as to comfortably adjust thepatient's legs to an angle of about 45°. The position of the cathetertip may be checked to determine no migration during position change ofthe patient.

Technique

Unlike earlier attempts to obliterate the saphenous vein by diathermy,the endovenous Closure procedure uses radiofrequency energy to heat thevein wall. The ClosurePLUS™ catheter employs intralumenally positionedbipolar electrodes located at the tip in contact with the vein wall.Electrical current flowing between the electrodes through the vein walltissue generates heat by a phenomenon called “resistive heating”. Thenew ClosureFAST™ catheter (illustrated in FIG. 1) utilizesradiofrequency energy to heat a 7 cm long element near the tip resultingin direct conduction to the vein wall.

In an embodiment, a distal section of a ClosureFAST catheter 10, whichcontains a 7 cm long heating element 15, is depicted heating the greatsaphenous vein (GSV) 20 in a segment starting approximately 2 cm belowthe saphenofemoral junction (SFJ) 25 in FIG. 1. FIG. 2 illustrates thecatheter 10 of FIG. 1 prior to heating an open segment 30 of the vein 20at a heating element 15, with a closed segment 35 of the vein 20 to theleft of the open segment 30 to be heated by heating element 15. FIG. 3illustrates seven segments 1-7 of the vein 20 where the heating coil orelement 15 is maintained during each energy delivery period. FIG. 4illustrates the tilt table 40 in a treatment room allows the torso ofthe patient to be in a relatively supine position (where patient's head50 can be seen to the right), while the leg 55 (to be treated) ispositioned with 30° or more of angulation θ.

For satisfactory transfer of energy, the electrodes or the element mustbe in direct contact with the vein wall. The heating causes a physicalshortening of the vein wall's collagen fibrils in a mostly uniformmanner, primarily in the subendothelial layers. (Manfrini S, Gasbarro V,Danielsson G, et al. Endovenous management of saphenous vein reflux. JVasc Surg. 2000;32:330-42.) A recent report by Schmedt et alcorroborates this finding. (Schmedt C G, Meissner O A, Hunger K, et al.Evaluation of endovenous radiofrequency ablation and laser therapy withendoluminal optical coherence tomography in an ex vivo model. J VascSurg. 2007;45:1047-58.) The vein diameter becomes narrowed while at thesame time denatured blood proteins congeal to obliterate the vein lumen.The entire treated vein is affected by this process much like softboiling an egg. Over the next several months, usually ten to twelve, andcertainly by two years, the vein fibroses and is seen to vanish onduplex ultrasound in over 86% of cases. (Pichot O, Kabnick L S, CretonD, et al. Duplex ultrasound scan findings two years after greatsaphenous vein radiofrequency endovenous obliteration. J Vasc Surg.2004;39:189-95.) For the ClosurePLUS procedure the process is controlledby a computerized generator (RF1 or RF2) which monitors electrodetemperature and adjusts energy levels to achieve a constant heating ofthe vein wall at a user-selectable temperature, typically 85° or 90°±3°C. During heating, the catheter is withdrawn from the vein typically ata rate of 2-4 centimeters per minute. For the ClosureFAST procedure thenewer RF2 generator (which can be used with all VNUS catheters) controlsthe heating element at 120° C. for a predetermined 20 second period thatcan be manually interrupted at any moment by the operator.

Major steps of the technique may be practiced as described herein.

Patient anesthesia, is generally a matter between the physician and thepatient. However, the procedure itself is well suited for localanesthesia or regional field block such as a femoral nerve block.General anesthesia offers at least one drawback in that the anesthetizedpatient is unable to communicate nerve pain which might be the result ofthe heat produced by the catheter coming into proximity with anoverlying sensory cutaneous nerve. Minimal sedation with oral (e.g.,diazepam) or intravenous (e.g., midazolam and fentanyl) agents isrecommended to provide adequate anxiolysis and analgesia. Short actingagents delivered intravenously have been found to offer better controlwith quick recovery and better patient comfort, thus allowing fast-trackpost procedure discharge from the facility or office. Midazolam I.V. (ofthe diazepam family) may offer some protection against lidocainetoxicity.

The catheter may be inserted into the vein at its nearest point to theskin surface, usually just below or above the knee using standardpercutaneous (Seldinger) or cut-down technique. The catheter tip ispositioned using ultrasound guidance approximately 2 cm distal to thesaphenofemoral junction. This is critical to avoid thermal injury to theSFJ. All current Closure devices (VNUS Medical Technologies, San Jose,Calif.) feature a central lumen that will accommodate either a 0.018(ClosureRFS™) or 0.025 inch (ClosurePLUS™ and ClosureFAST™ ) diameterguide wire, to allow maneuverability through tortuous or difficult veinsegments.

Once the catheter has been positioned safely below the SFJ, tumescentanesthesia can be introduced using a variety of methods. It is importantto use ultrasound visualization in order to insure that the fluid isplaced beneath the saphenous fascia and above the deep muscular fasciaand that it surrounds the vein completely, which serves to contain theradiant heat within the treated vein without significantly affectingadjacent cutaneous and sensory nerve tissues. (Zikorus A W, Mirizzi M S.Evaluation of setpoint temperature and pullback speed on veinadventitial temperature during endovenous radiofrequency energy deliveryin an in-vitro model. Vasc Endovascular Surg. 2004;38:167-74.) Theinfusate also compresses the saphenous vein and its inflow branches inorder to produce a “dry” vein. Contraction of the vein diameter isanother benefit if diluted epinephrine is included in the tumescentanesthetic fluid. Tumescent anesthesia, using generous volumes ofbuffered lidocaine 1% with epinephrine 1:100,000 diluted to 0.1% placedproperly, results in relatively pain free status (see Table 1). Caremust be taken to avoid lidocaine toxicity. For example, dosageguidelines are 7 mg/kg body weight, and no more than 500 mg should beused at one setting. Bilateral limb procedures may require alternateanesthesia choice such as general or regional (e.g., femoral nerveblock, spinal, or epidural).

Prior to November 2007, during vein heating the patient was positionedin gentle Trendelenburg position, approximately 15-20 degrees. Morerecently, as depicted in FIG. 2, the patient's head and torso are keptin a relatively comfortable horizontal position while the limb to betreated is elevated at an angle of 30-45 degrees. Ultrasound imagingdemonstrates that, while the patient remains comfortable, this extremeposition allows for near complete emptying of the venous system withtight circumferential contact of the vein by the catheter. Gentle manualpressure with the diagnostic ultrasound (DUS) probe can be applied tothe saphenofemoral junction area and then along the course of the veinas necessary, while the catheter is withdrawn (for ClosurePLUS) orsegmentally repositioned (for ClosureFAST).

DUS should be used to document satisfactory closure of the treated veinjust before removing the catheter from the vein. When ClosurePLUS isperformed, a curious finding on ultrasound that may be observed isechogenic movement depicted in the occluded vein despite havingobliterated the lumen. It probably represents movement of salinesolution infused through the Closure catheter in the vein and around theblood plug despite adequate obliteration of the lumen. If significantflow remains, the vein should be retreated. When using the ClosureFASTcatheter the catheter may not be re-advanced to the SFJ, as doing so maydislodge fibrinous material cephalad into the proximal deep venoussystem. If there are concerns when treating very large diameter veins,approximately 10 mm or greater, one can simply double heat each 7 cmsegment (i.e., two episodes, 20 seconds each) prior to repositioning thecatheter. The transfer of heat with ClosureFAST is so uniform andefficient that the vein treated invariably closes when studiedpostoperatively with DUS.

The patient should be encouraged to ambulate immediately, returning insome cases to normal activities on the same day. Postoperativeultrasound imaging of the saphenofemoral junction within three days is apart of the protocol to check for successful obliteration and absence ofclot extension into the common femoral vein. What is usually seen atthis initial check is remarkably similar to an acute thrombosis of thevein with dilation and filling of the vein lumen with echo dense signalsand failure to compress with externally applied pressure. Thisrepresents an element of thrombosis which aids the obliteration process.

Management of Complications

Data collected for the VNUS Closure Study Group Registry wasprospective, looking for nerve injury, clot extension, hematoma,phlebitis, skin burns, and infection. (Merchant R F, DePalma R G,Kabnick L S. Endovascular obliteration of saphenous reflux: Amulticenter study. J Vasc Surg. 2002;35:1190-6.) Only limbs treated at85° C. and seen within the first postoperative week were included in thereport, and only limbs treated with Closure and ClosurePLUS catheterswere included in the Registry. Results are shown in Table 2. The mostserious complication, although rare, is clot extension into the commonfemoral vein as it can lead to deep vein thrombosis (DVT) if notrecognized and treated early with either low molecular weight heparin(LMWH) or operative thrombectomy. It is a general practice to see allcases on the first postoperative day and to include a postoperativeduplex scan during that visit. If there is evidence of clot extendinginto the deep vein, then LMWH is prescribed at therapeutic doses for sixdays. Aspirin 325 mg is started on day 7 and continued for one month.

Nerve injury associated with RF ablation is seen as areas ofhypoesthesia noted on follow-up examination in the first week post-op.The majority of these occurred in the early Closure cases before theroutine instillation of tumescent anesthesia. To avoid nerve injury,following the early clinical experience, the Closure procedure wasrecommended to be limited to above knee great saphenous vein (GSV)treatments. (Manfrini S, Gasbarro V, Danielsson G, et al. Endovenousmanagement of saphenous vein reflux. J Vasc Surg. 2000;32:330-42.) Thegreater saphenous nerve is actually adherent to the GSV in the distalleg and injury to this nerve is usually unavoidable when GSV RF ablationis attempted much below the knee. (Chandler J G, Pichot O, Sessa C, etal. Treatment of primary venous insufficiency by endovenous saphenousvein obliteration. Vasc Surg. 2000;34:201-14.)

Skin burns, initially seen in a minority of early Closure cases,essentially have vanished since the institution of tumescent anesthesia(Merchant R F, DePalma R G, Kabnick L S. Endovascular obliteration ofsaphenous reflux: A multicenter study. J Vasc Surg. 2002;35: 1190-6, andWeiss R A, Weiss M A. Controlled radiofrequency endovenous occlusionusing a unique radiofrequency catheter under duplex guidance toeliminate saphenous varicose vein reflux: A 2-year follow-up. DermatolSurg. 2002;28:38-42.) and the abandonment of the Eschmark leg wrap. TheEschmark rubber bandage has a tendency to roll back when applied to thefunnel shaped thigh, in which case it can act as a tight rubber band topush the skin closer to the saphenous vein. Ablation in the thin orskinny leg should prompt careful attention to detail to minimize thermalinjuries to the overlying skin due to excessive external compression,which can arise from the Eschmark bandage or the DUS probe duringintraoperative monitoring.

Phlebitis can occur with the Closure procedure as in any treatment ofvaricose veins, and it is usually the result of residual blood trappedwithin vein segments. Some degree of phlebitis is inherent in the wholeprocess since the obliteration occurs as a result of injury to the veinby the heating process. It is occasionally seen as a tender,erythematous or ecchymotic band over the treated vein in the distalthigh. It resolves over several weeks without any specific treatmentother than for symptomatic relief, e.g. the use of non-steroidalanti-inflammatory drugs, heat, and compression hosiery.

Patients may describe a curious sensation which occurs during the secondor third post-op week along the treated vein segment, usually in thedistal thigh. They may experience a spontaneous or persistent dullfeeling, or “bogginess”, or sharpness when stretching or extending thetreated leg. This could represent an inflammatory process which occursas the body is healing the scald injury of the treated vein segment. Thesensations usually abate over several weeks, consistent with the normalhealing time of injured tissues.

ClosureFAST

The endovenous Closure procedure has evolved from the originallyintroduced catheter and techniques, to introduction of improved devices(ClosurePLUS, ClosureFAST) and techniques (tumescence) designed toimprove outcomes and reduce the incidence of complications, and newlydesigned devices (ClosureRFS) to broaden applications. The introductionof the ClosureFAST catheter in 2007 was intended to substantiallyshorten procedure time and it appears that it has done just so. Thedevice has a 7 cm heating element that remains stationary during a20-second long energy delivery period. The catheter is then repeatedlyretracted 6.5 cm and energized for 20 seconds at each segment until thedesired length of vein has been treated. The ClosureFAST catheter hasundergone successful early clinical studies. Proebstle et al reported onthe first multi-center study of 252 GSVs treated in 194 patients. Theaverage energy delivery time was 2.2 minutes over an average 36.7cm veinlength; 16.4 minutes average elapsed time from catheter insertion tofinal removal. Initial vein occlusion was 100% and life-table analysisout to 6 months was 99.6% occlusion rate. (Proebstle T M, Vago B, Alm J,Göckeritz O, Lebard C, Pichot O. Treatment of the incompetent greatsaphenous vein by endovenous radiofrequency powered segmental thermalablation: first clinical experience. J Vasc Surg. 2008;47:151-156.) Infollow-up, Proebstle reported a 96.7% occlusion rate on 223 veinsegments at one year. (Proebstle T M, Vago B, Alm J, Göckeritz O, LebardC, Pichot O. One year follow-up of radiofrequency segmental thermalablation (RTFA)-of great saphenous veins. Presented at American VenousForum 20^(th) annual meeting, Feb. 20-23, 2008; Charleston, S.C.)

The Reno Vein Clinic began using ClosureFAST in May 2007, and byNovember 2007 had treated 138 saphenous vein segments of which 15 wereSSV treatments. Within the first six months, only one segment hadcompletely recanalized, and the complication rates were similar to theClosurePLUS procedure. However, in several instances there were multipleinterruptions of the procedure due to inadequate or uneven heating ofthe vein segments, which resulted in damage to the heating elementportion of six ClosureFAST catheters. In November 2007 an adjustment wasmade in what proved to be a significant improvement to the technique—thelimb undergoing treatment was elevated 30-45 degrees from the horizontalto effect complete emptying of the superficial venous system (see FIG.2). DUS demonstrated complete emptying of the saphenous vein withtumescence and elevation. Implementation of this maneuver resolved theuneven heating problem, and the average energy delivered to the veinsegments dropped from 110 Joules/cm to 60 Joules/cm (average of twoprocedure measurements). From November 2007 to October 2008 onehundred-thirty-one (131) saphenous vein segments (of which 18 were SSV)were treated with 100% initial occlusion and absence of hypoesthesia anddeep venous thrombosis related to the RF procedure. Interruptions ceasedand there were no further episodes of heat related catheter damage. Onepatient suffered a second degree skin burn at the insertion site,probably as a result of inadvertent positioning of the catheter in theintroducer sheath during the final segment treatment.

Three key points of the ClosureFAST technique should be emphasized toassure a smooth and successful treatment of the patient:

To avoid possible thermal injury to the SFJ, the catheter tip must bepositioned 2 cm distal to the SFJ, regardless of superficial epigastricvein location. One must reaffirm location by longitudinal and transverseDUS images.

There is a step-up hub located 2 cm behind the heating element; use thisindicator to locate the position of the catheter beneath the skin at theinsertion site during the final segment treatment. This should helpavoid skin burns at this location.

Elevate the limb to be treated, either manually or by table reposition,30-45 degrees during the short two to four minute treatment course. Thisprovides complete emptying of the vein segment and allows a smooth,uninterrupted procedure.

The evidence published in peer reviewed journals, four studies of whichare level one, suggests that at least out to five years outcomes of RFobliteration of saphenous vein reflux are comparable to traditionalstripping and ligation. The risks of serious complications such as DVTare low and comparable with those that attend stripping and ligation.Lesser complications, when they do occur, are time limited and usuallyof minor consequence.

Using the RF Closure equipment and employing current techniquesdescribed in this report, an experienced clinician, modifying details tosuit individual clinical settings, can expect the following: 1) 98-100%successful initial ablation; 2) less than 1 % rate of complications suchas common femoral vein clot extension and DVT, temporary sensory thermalnerve injury and second degree thermal skin injury; and 3) five-yearablation and reflux-free outcomes of >90%. In high risk patients, e.g.the obese, or those on anticoagulation or having co-morbidities, theClosure procedures may be the better treatment option because of theadvantages they offer over traditional surgical methods, especiallyregarding less trauma. In cases where reflux originates distal to thesaphenofemoral junction (which can only be appreciated by DUS), theClosure method is ideally suited.

Neovascularization following this procedure at the saphenofemoraljunction appears to only rarely occur and may not be a factor in laterrecurrent varicose veins, a possible distinct advantage in comparisonwith surgical stripping and high ligation. (Pichot O, Kabnick L S,Creton D, et al. Duplex ultrasound scan findings two years after greatsaphenous vein radiofrequency endovenous obliteration. J Vasc Surg.2004;39:189-95; and Kianifard B, Holdstock J M, Whiteley M S.Radiofrequency ablation (VNUS closure) does not causeneo-vascularisation at the groin at one year: results of a casecontrolled study. Surgeon. 2006;4:71-4.) The persistent patency found inthe superficial epigastric vein and other less frequently seen groinbranches and the pattern of failures of the Closure procedure have beendescribed recently in the five-year report by the Closure Study Groupand the results are encouraging for long term successful relief fromsuperficial venous hypertension and reflux. There is little reason todoubt that results with the new ClosureFAST segmental heating catheterwould be any different, if not better; short term reports support thisassertion. (Proebstle T M, Vago B, Alm J, Göckeritz O, Lebard C, PichotO. One year follow-up of radiofrequency segmental thermal ablation(RTFA) of great saphenous veins. Presented at American Venous Forum20^(th) annual meeting, Feb. 20-23, 2008; Charleston, S.C.)

Radiofrequency obliteration of saphenous vein reflux, given the caveatthat it be done by a qualified physician, has become a safe, effective,and preferred alternative to traditional surgical techniques, evidencedby many publications including the Closure Study Group five-yearoutcomes. Schmedt et al, reporting certain anatomical findings by aninnovative research investigational tool, endoluminal optical coherencetomography (eOCT), demonstrated a more uniform and completedisintegration of the radiofrequency (ClosurePLUS, 6Fr) treated bovinevein compared to endovenous laser treated bovine vein. (Schmedt C G,Meissner O A, Hunger K, et al. Evaluation of endovenous radiofrequencyablation and laser therapy with endoluminal optical coherence tomographyin an ex vivo model. J Vasc Surg. 2007;45:1047-58.) Whetherradiofrequency deserves to be the treatment of choice among endovenousobliteration procedures will require further well designed randomizedstudies. In the meantime it makes sense to offer this innovativetechnology as a primary choice for the patient with saphenous veinreflux of primary origin.

TABLE 1 Tumescent anesthesia solution preparation Ringer's Lactate 500cc Withdraw 50 cc −50 cc 450 cc Add lidocaine 1% with epinephrine +50 cc1:100,000 500 cc Add sodium bicarbonate (NaHCO₃) +16 cc 8.4% Resultantsolution is lidocaine 0.1% 516 cc with epinephrine 1:1 million

TABLE 2 Complications reported from the Closure Study Group Follow-upRate of occurrence, Complication interval % (n/N) DVT (accompanied bypulmonary One week 1.0 (3/286) embolism in one instance) Skin burn -first half of study One week 4.2 (6/143) Skin burn - second half ofstudy One week   0 (0/143) Infection One week   0 (0/286) Clinicalphlebitis One week 2.1 (6/286) Clinical phlebitis Six months 0.4 (1/223)Paresthesia One week 15.0 (43/286) Paresthesia Six months  9.4 (21/223)Paresthesia 12 months 3.9 (9/232) Paresthesia 24 months 5.6 (8/142)

1. A method of vein closure, the method comprising: elevating a leg of apatient during a vein closure procedure so as to effect substantialemptying of the vein; and applying radio-frequency (RF) energy to a veinwithin the leg of the patient to cause the vein closure, wherein theradio-frequency (RF) energy is applied with a heating coil of a catheterwithin the vein during the procedure.
 2. A method in accordance withclaim 1, further comprising application of light pressure on the heatingcoil of the catheter during an initial period of energy delivery.
 3. Amethod in accordance with claim 2, further comprising drawing theheating coil of the catheter through the vein within the leg of thepatient without any external pressure being applied subsequent to theapplication of light pressure on the heating coil of the catheter duringan initial period of energy delivery.
 4. A method in accordance withclaim 1, further comprising drawing the heating coil of the catheterthrough the vein within the leg of the patient without any externalpressure being applied to the heating coil of the catheter.
 5. A methodin accordance with claim 1, further comprising completing the veinclosure procedure for the leg in a period of time of less than 2 minutesfrom an initial application of the radio-frequency (RF) energy to thevein within the leg of the patient.
 6. A method in accordance with claim1, further comprising positioning a distal end of the catheter about 2cm distal to the saphenofemoral junction.
 7. A method in accordance withclaim 6, wherein the positioning of the distal end of the catheteroccurs without regard to superficial epigastric vein location.
 8. Amethod in accordance with claim 1, further comprising using a step-uphub located about 2 cm behind the heating coil to locate the catheterbeneath the skin at an intersection site during a final segmenttreatment.
 9. A method in accordance with claim 1, wherein the elevatingthe leg of the patient during the vein closure procedure is within arange of about 30 degrees to about 45 degrees from a horizontalposition.
 10. A method in accordance with claim 1, further comprisingemptying of a segment the vein prior to applying the radio-frequency(RF) energy to the segment of the vein.
 11. A method in accordance withclaim 10, further comprising providing tight circumferential contact ofthe vein by the catheter simulations to the emptying of the segment ofthe vein.
 12. A method in accordance with claim 1, further comprisingintroducing tumescent anesthesia so as to effect complete emptying ofthe vein.
 13. A method in accordance with claim 1, further comprisingmaintaining the heating coil stationary during an energy deliveryperiod.
 14. A method in accordance with claim 12, further comprisingretracting the catheter after the delivery period.
 15. A method inaccordance to claim 14, where in the energy delivery period is 20seconds.
 16. A method in accordance to claim 14, wherein the heatingcoil is 7 cm in length and the catheter is retracted 6.5 cm after eachdelivery period.
 17. A method of vein closure, the method comprising:elevating a leg of a patient during a vein closure procedure within arange of about 30 degrees to about 45 degrees from a horizontalposition; and applying radio-frequency (RF) energy to a vein within theleg of the patient to cause the vein closure with the leg of the patientelevated within the range of about 30 degrees to about 45 degrees.
 18. Amethod of vein closure, the method comprising: elevating a leg of apatient during a vein closure procedure; emptying of a segment the veinprior to applying radio-frequency (RF) energy to a segment of the vein;and applying the radio-frequency (RF) energy to the vein within the legof the patient to cause the vein closure.
 19. A method of vein closure,the method comprising: elevating a leg of a patient during a veinclosure procedure so as to effect substantial emptying of the vein; andapplying energy to a vein within the leg of the patient to cause thevein closure, wherein the energy is applied to the vein during theprocedure.
 20. A method in accordance to claim 19, wherein the energy isprovided by a laser.
 21. A method in accordance to claim 19, wherein theenergy is steam.
 22. A method in accordance to claim 19, wherein theenergy is electromagnetic energy.